Business of Medicine

Despite an increasingly diverse workforce, a new study has found that many patients remain biased toward certain physicians, which can produce substantial negative – and occasionally positive – effects.

“Addressing demeaning behavior from patients will require a concerted effort from medical schools and hospital leadership to create an environment that respects the diversity of patients and physicians alike,” wrote Margaret Wheeler, MD, of the University of California, San Francisco (UCSF) and her coauthors. The study was published in JAMA Internal Medicine.

To determine the perspectives of physicians and trainees in regard to patient bias, along with potential barriers to responding effectively, the researchers led 13 focus groups attended by internal 11 medicine hospitalist physicians, 26 internal medicine residents, and 13 medical students affiliated with the UCSF School of Medicine. In terms of gender, 26 participants identified as women, 22 as men, and 2 as gender nonconforming. In terms of racial and ethnic diversity, 26 were white, 8 were Latinx, 7 were Asian, 3 were South Asian, 1 was Middle Eastern, and 5 were black.

In describing biased and demeaning patient behavior, the participants recalled remarks that ranged from refusal of care and questioning the clinician’s role to ethnic jokes, questions as to their ethnic backgrounds, inappropriate flirtations or compliments. The effects of these behaviors on the participants included negative responses like carrying an emotional burden and withdrawing from work, along with positive responses like an increased desire for self-growth and to pursue leadership opportunities.

Barriers to addressing these behaviors included a lack of support, uncertainty as to the appropriate response, and a fear of being perceived as unprofessional. Deciding how to respond – or to respond at all – was often dictated by the level of support from colleagues, a professional responsibility to peers, and the presence of a positive role model who would’ve done the same.

The authors acknowledged their study’s limitations, including only knowing the views of those who were interviewed. In addition, all participants came from a medical school located in a diverse city that embraces different cultures, meaning their findings “may not reflect the experiences of physicians in other geographic regions.”

The study was supported by the Greenwall Foundation. The authors reported no conflicts of interest.

SOURCE: Wheeler M et al. JAMA Intern Med. 2019 Oct 28. doi: 10.1001/jamainternmed.2019.4122.

Despite an increasingly diverse workforce, a new study has found that many patients remain biased toward certain physicians, which can produce substantial negative – and occasionally positive – effects.

“Addressing demeaning behavior from patients will require a concerted effort from medical schools and hospital leadership to create an environment that respects the diversity of patients and physicians alike,” wrote Margaret Wheeler, MD, of the University of California, San Francisco (UCSF) and her coauthors. The study was published in JAMA Internal Medicine.

To determine the perspectives of physicians and trainees in regard to patient bias, along with potential barriers to responding effectively, the researchers led 13 focus groups attended by internal 11 medicine hospitalist physicians, 26 internal medicine residents, and 13 medical students affiliated with the UCSF School of Medicine. In terms of gender, 26 participants identified as women, 22 as men, and 2 as gender nonconforming. In terms of racial and ethnic diversity, 26 were white, 8 were Latinx, 7 were Asian, 3 were South Asian, 1 was Middle Eastern, and 5 were black.

In describing biased and demeaning patient behavior, the participants recalled remarks that ranged from refusal of care and questioning the clinician’s role to ethnic jokes, questions as to their ethnic backgrounds, inappropriate flirtations or compliments. The effects of these behaviors on the participants included negative responses like carrying an emotional burden and withdrawing from work, along with positive responses like an increased desire for self-growth and to pursue leadership opportunities.

Barriers to addressing these behaviors included a lack of support, uncertainty as to the appropriate response, and a fear of being perceived as unprofessional. Deciding how to respond – or to respond at all – was often dictated by the level of support from colleagues, a professional responsibility to peers, and the presence of a positive role model who would’ve done the same.

The authors acknowledged their study’s limitations, including only knowing the views of those who were interviewed. In addition, all participants came from a medical school located in a diverse city that embraces different cultures, meaning their findings “may not reflect the experiences of physicians in other geographic regions.”

The study was supported by the Greenwall Foundation. The authors reported no conflicts of interest.

SOURCE: Wheeler M et al. JAMA Intern Med. 2019 Oct 28. doi: 10.1001/jamainternmed.2019.4122.

Despite an increasingly diverse workforce, a new study has found that many patients remain biased toward certain physicians, which can produce substantial negative – and occasionally positive – effects.

“Addressing demeaning behavior from patients will require a concerted effort from medical schools and hospital leadership to create an environment that respects the diversity of patients and physicians alike,” wrote Margaret Wheeler, MD, of the University of California, San Francisco (UCSF) and her coauthors. The study was published in JAMA Internal Medicine.

To determine the perspectives of physicians and trainees in regard to patient bias, along with potential barriers to responding effectively, the researchers led 13 focus groups attended by internal 11 medicine hospitalist physicians, 26 internal medicine residents, and 13 medical students affiliated with the UCSF School of Medicine. In terms of gender, 26 participants identified as women, 22 as men, and 2 as gender nonconforming. In terms of racial and ethnic diversity, 26 were white, 8 were Latinx, 7 were Asian, 3 were South Asian, 1 was Middle Eastern, and 5 were black.

In describing biased and demeaning patient behavior, the participants recalled remarks that ranged from refusal of care and questioning the clinician’s role to ethnic jokes, questions as to their ethnic backgrounds, inappropriate flirtations or compliments. The effects of these behaviors on the participants included negative responses like carrying an emotional burden and withdrawing from work, along with positive responses like an increased desire for self-growth and to pursue leadership opportunities.

Barriers to addressing these behaviors included a lack of support, uncertainty as to the appropriate response, and a fear of being perceived as unprofessional. Deciding how to respond – or to respond at all – was often dictated by the level of support from colleagues, a professional responsibility to peers, and the presence of a positive role model who would’ve done the same.

The authors acknowledged their study’s limitations, including only knowing the views of those who were interviewed. In addition, all participants came from a medical school located in a diverse city that embraces different cultures, meaning their findings “may not reflect the experiences of physicians in other geographic regions.”

The study was supported by the Greenwall Foundation. The authors reported no conflicts of interest.

SOURCE: Wheeler M et al. JAMA Intern Med. 2019 Oct 28. doi: 10.1001/jamainternmed.2019.4122.

SAN FRANCISCO – Nearly one in three surgical residents report experiencing gender-based discrimination, and one in six report racial discrimination, with mistreatment linked to burnout and suicidal thoughts, according to data presented at the annual clinical congress of the American College of Surgeons.

Published simultaneously in the New England Journal of Medicine, the cross-sectional national survey of 7,409 residents across all 262 surgical residency programs investigated the impact of mistreatment on burnout rates and suicidal thoughts. The sample included 99.3% of all eligible U.S. trainees.

The survey found that 31.9% of all respondents – 65.1% of women and 10% of men – said they had experienced discrimination because of their self-reported gender, and 16.6% had experienced racial discrimination. In the case of both gender-based and racial discrimination, nearly half of respondents who had experienced these identified patients and patients’ families as the source.

One-third of female respondents (33%) had been on the receiving end of verbal emotional abuse, as had 28.3% of male respondents. Most of the abuse came from other surgeons.

Around 1 in 10 residents – 19.9% of women and 3.9% of men – had experienced sexual harassment. In around one-third of cases, the source was other surgeons, and in one-third the source was patients and their families.

Nearly half of all the residents said they had experienced some form of mistreatment, 19% said they experienced it a few times a month, and 30.9% said it happened a few times a year.

The survey found that 38.5% of residents experienced the symptoms of burnout – such as emotional exhaustion and depersonalization – at least once a week. The incidence was higher in women than in men (42.4% vs. 35.9%), with women reporting a higher prevalence of emotional exhaustion than men. Nearly 1 in 20 (4.5%) reported having suicidal thoughts (5.3% of women and 3.9% of men).

Researchers found that the more mistreatment a resident experienced, the greater the frequency of burnout symptoms. Those who reported experiencing mistreatment a few times a year had a twofold greater odds of burnout, compared with those who had not experienced any mistreatment. Those who experienced mistreatment a few times a month or more had nearly threefold higher odds of burnout. Similarly, increasing exposure to mistreatment was also associated with stepwise increases in the odds of suicidal thoughts.

“Mistreatment is a frequent experience for general surgery residents in the United States, and is associated with burnout and suicidal thoughts,” wrote Yue-Yung Hu, MD, from the Surgical Outcomes and Quality Improvement Center at Northwestern University, Chicago, and coauthors. “Our results provide initial insights on how we may build safer, more equitable and more effective education environments for trainees.”

The study was supported by the American College of Surgeons, the Accreditation Council for Graduate Medical Education, and the American Board of Surgery. Two authors were supported by grants from the Agency for Healthcare Research and Quality, and one by a grant from the National Institutes of Health. One author was an employee of the Accreditation Council for Graduate Medical Education.

SOURCE: Hu Y-Y et al. N Engl J Med. 2019 Oct 28. doi: 10.1056/NEJMsa1903759.

SAN FRANCISCO – Nearly one in three surgical residents report experiencing gender-based discrimination, and one in six report racial discrimination, with mistreatment linked to burnout and suicidal thoughts, according to data presented at the annual clinical congress of the American College of Surgeons.

Published simultaneously in the New England Journal of Medicine, the cross-sectional national survey of 7,409 residents across all 262 surgical residency programs investigated the impact of mistreatment on burnout rates and suicidal thoughts. The sample included 99.3% of all eligible U.S. trainees.

The survey found that 31.9% of all respondents – 65.1% of women and 10% of men – said they had experienced discrimination because of their self-reported gender, and 16.6% had experienced racial discrimination. In the case of both gender-based and racial discrimination, nearly half of respondents who had experienced these identified patients and patients’ families as the source.

One-third of female respondents (33%) had been on the receiving end of verbal emotional abuse, as had 28.3% of male respondents. Most of the abuse came from other surgeons.

Around 1 in 10 residents – 19.9% of women and 3.9% of men – had experienced sexual harassment. In around one-third of cases, the source was other surgeons, and in one-third the source was patients and their families.

Nearly half of all the residents said they had experienced some form of mistreatment, 19% said they experienced it a few times a month, and 30.9% said it happened a few times a year.

The survey found that 38.5% of residents experienced the symptoms of burnout – such as emotional exhaustion and depersonalization – at least once a week. The incidence was higher in women than in men (42.4% vs. 35.9%), with women reporting a higher prevalence of emotional exhaustion than men. Nearly 1 in 20 (4.5%) reported having suicidal thoughts (5.3% of women and 3.9% of men).

Researchers found that the more mistreatment a resident experienced, the greater the frequency of burnout symptoms. Those who reported experiencing mistreatment a few times a year had a twofold greater odds of burnout, compared with those who had not experienced any mistreatment. Those who experienced mistreatment a few times a month or more had nearly threefold higher odds of burnout. Similarly, increasing exposure to mistreatment was also associated with stepwise increases in the odds of suicidal thoughts.

“Mistreatment is a frequent experience for general surgery residents in the United States, and is associated with burnout and suicidal thoughts,” wrote Yue-Yung Hu, MD, from the Surgical Outcomes and Quality Improvement Center at Northwestern University, Chicago, and coauthors. “Our results provide initial insights on how we may build safer, more equitable and more effective education environments for trainees.”

The study was supported by the American College of Surgeons, the Accreditation Council for Graduate Medical Education, and the American Board of Surgery. Two authors were supported by grants from the Agency for Healthcare Research and Quality, and one by a grant from the National Institutes of Health. One author was an employee of the Accreditation Council for Graduate Medical Education.

SOURCE: Hu Y-Y et al. N Engl J Med. 2019 Oct 28. doi: 10.1056/NEJMsa1903759.

SAN FRANCISCO – Nearly one in three surgical residents report experiencing gender-based discrimination, and one in six report racial discrimination, with mistreatment linked to burnout and suicidal thoughts, according to data presented at the annual clinical congress of the American College of Surgeons.

Published simultaneously in the New England Journal of Medicine, the cross-sectional national survey of 7,409 residents across all 262 surgical residency programs investigated the impact of mistreatment on burnout rates and suicidal thoughts. The sample included 99.3% of all eligible U.S. trainees.

The survey found that 31.9% of all respondents – 65.1% of women and 10% of men – said they had experienced discrimination because of their self-reported gender, and 16.6% had experienced racial discrimination. In the case of both gender-based and racial discrimination, nearly half of respondents who had experienced these identified patients and patients’ families as the source.

One-third of female respondents (33%) had been on the receiving end of verbal emotional abuse, as had 28.3% of male respondents. Most of the abuse came from other surgeons.

Around 1 in 10 residents – 19.9% of women and 3.9% of men – had experienced sexual harassment. In around one-third of cases, the source was other surgeons, and in one-third the source was patients and their families.

Nearly half of all the residents said they had experienced some form of mistreatment, 19% said they experienced it a few times a month, and 30.9% said it happened a few times a year.

The survey found that 38.5% of residents experienced the symptoms of burnout – such as emotional exhaustion and depersonalization – at least once a week. The incidence was higher in women than in men (42.4% vs. 35.9%), with women reporting a higher prevalence of emotional exhaustion than men. Nearly 1 in 20 (4.5%) reported having suicidal thoughts (5.3% of women and 3.9% of men).

Researchers found that the more mistreatment a resident experienced, the greater the frequency of burnout symptoms. Those who reported experiencing mistreatment a few times a year had a twofold greater odds of burnout, compared with those who had not experienced any mistreatment. Those who experienced mistreatment a few times a month or more had nearly threefold higher odds of burnout. Similarly, increasing exposure to mistreatment was also associated with stepwise increases in the odds of suicidal thoughts.

“Mistreatment is a frequent experience for general surgery residents in the United States, and is associated with burnout and suicidal thoughts,” wrote Yue-Yung Hu, MD, from the Surgical Outcomes and Quality Improvement Center at Northwestern University, Chicago, and coauthors. “Our results provide initial insights on how we may build safer, more equitable and more effective education environments for trainees.”

The study was supported by the American College of Surgeons, the Accreditation Council for Graduate Medical Education, and the American Board of Surgery. Two authors were supported by grants from the Agency for Healthcare Research and Quality, and one by a grant from the National Institutes of Health. One author was an employee of the Accreditation Council for Graduate Medical Education.

SOURCE: Hu Y-Y et al. N Engl J Med. 2019 Oct 28. doi: 10.1056/NEJMsa1903759.

Clinical Psychiatry News is pleased to announce the addition of three physicians to its editorial advisory board: Constance E. Dunlap, MD; Eva Ritvo, MD; and Linda L.M. Worley, MD.

Dr. Dunlap, a psychiatrist and psychoanalyst, is a Washington Psychiatric Society representative to the American Psychiatric Association (APA) Assembly, a past president of the Washington Psychiatric Society, and clinical professor of psychiatry and behavioral sciences at George Washington University, Washington.

*This story was updated 2/26/2020.

Clinical Psychiatry News is pleased to announce the addition of three physicians to its editorial advisory board: Constance E. Dunlap, MD; Eva Ritvo, MD; and Linda L.M. Worley, MD.

Dr. Dunlap, a psychiatrist and psychoanalyst, is a Washington Psychiatric Society representative to the American Psychiatric Association (APA) Assembly, a past president of the Washington Psychiatric Society, and clinical professor of psychiatry and behavioral sciences at George Washington University, Washington.

*This story was updated 2/26/2020.

Clinical Psychiatry News is pleased to announce the addition of three physicians to its editorial advisory board: Constance E. Dunlap, MD; Eva Ritvo, MD; and Linda L.M. Worley, MD.

Dr. Dunlap, a psychiatrist and psychoanalyst, is a Washington Psychiatric Society representative to the American Psychiatric Association (APA) Assembly, a past president of the Washington Psychiatric Society, and clinical professor of psychiatry and behavioral sciences at George Washington University, Washington.

*This story was updated 2/26/2020.

Whether a board member for the American Academy of Dermatology and the AAD Association (AAD/A) violated his fiduciary duties by launching an organization that offered board certification to physician assistants (PAs) will soon be decided by AAD members.

In mid-October, the AAD/A board of directors unanimously agreed to present AAD members with a resolution to remove Scott M. Dinehart, MD, from his position on the board. AAD President George J. Hruza, MD, said Dr. Dinehart violated his duties when he became sole organizer of the American Board of Dermatology Physician Assistants (ABDPA), an organization that planned to offer board certification to PAs who work with dermatologists, according to a message from Dr. Hruza to members. The use of the words “American Board of Dermatology” in the ABDPA name created confusion to patients and threatened to undermine the value of ABD certification held by AAD/A fellows, Dr. Hruza said.

“Dr. Dinehart’s action to incorporate and organize the for-profit entity ABDPA, LLC., is in direct contradiction to the AAD’s Truth in Advertising and Professional Disclosure policy that states that practitioners should not advertise that they are board certified unless they are certified by an ABMS/AOA [American Board of Medical Specialties or American Osteopathic Association] medical board, such as the American Board of Dermatology,” Dr. Hruza said in an interview with Dermatology News. “This for-profit venture would enable physician assistants to advertise themselves as board certified. The [AAD/A] board in its unanimous decision deemed that the new ABDPA was set up to potentially mislead patients into thinking that physician assistants with this certification would have training and experience equivalent to an ABD-certified dermatologist. This is contrary to the AAD/A’s position on this matter. As such, Dr. Dinehart’s involvement in forming and organizing the ABDPA violated his fiduciary duty to act in the best interests of the AAD/A and to abide by AAD/A policies.”

In a letter to AAD members, Dr. Dinehart called the removal vote a “drastic measure” and said he has done nothing to justify dismissal from the AAD/A board. The ABDPA was intended to improve patient care by establishing certain educational, training, and professional standards for the growing number of physician assistants in dermatology, Dr. Dinehart wrote. That mission was not in conflict with AAD’s values, but rather, the ABDPA would have furthered AAD’s purpose “to promote the highest standards in allied health professionals and services as they relate to dermatology.”

After learning of the board’s concerns, Dr. Dinehart said he discontinued his relationship with the ABDPA and ensured its operations had ended out of respect for the academy. He believes the matter could have been handled much differently.

“I did not violate any bylaws,” Dr. Dinehart said in an interview with Dermatology News. “While I understand that there are certain members of the AAD that personally oppose the growing use of physician assistants in dermatology practices, it is a common practice among many AAD members, and it is not contrary to or detrimental to any of the purposes of the AAD.”

Dr. Dinehart contends he did not run afoul of the AAD/A’s position statement on Truth in Advertising and Professional Credential Disclosure because the statement pertains to AAD/A members and prohibits members from advertising board certifications by nonapproved boards. He emphasized that PAs are not members and said he would never represent or advertise a physician assistant as having a certification equivalent to a board-certified dermatologist or being capable of equivalent credentials.

In addition, he said his involvement with the new organization did not conflict with the AAD’s Practice of Dermatology: Protecting and Preserving Patient Safety and Quality Care position statement, which opposes the independent or unsupervised practice of dermatology procedures by nonphysicians.

“Neither the ADBPA nor the certification it intended to offer would have allowed physician assistants to engage in the independent or unsupervised practice of specific dermatology procedures, and any physician assistant who did so would be subject to the same repercussions that currently exist,” Dr. Dinehart said in the interview.

The ABDPA was formed legally at the end of September and announced its official launch on Oct. 7. The new organization immediately drew criticism from dermatologists and triggered an online petition that denounced the group and called for Dr Dinehart’s removal from the AAD/A board. The petition, started by an anonymous dermatologist, states Dr. Dinehart’s concurrent relationships with the AAD and the ABDPA represent a major conflict of interest. As of Oct. 24, the petition had collected 2,496 signatures.

Monica Madray, MD, a dermatologist based in Georgetown, Tex., who signed the petition, said the ABDPA further muddied the waters in an already confusing world of “providers” and non–dermatology boarded physicians practicing and advertising themselves as dermatologists.

“Patients truly don’t know the difference in training between physicians and midlevels, and by ‘board certifying’ PAs in dermatology, it gets much more confusing,” Dr. Madray said in an interview. “I also think there was a huge financial conflict of interest for Dr. Dinehart to start and run this board as he oversees many midlevels. Frankly, it didn’t pass the sniff test.”

Vivian Bucay, MD, a dermatologist based in San Antonio who signed the petition, said that, if Dr. Dinehart was interested in starting an organization such as the ABDPA, he should have first presented the idea to the AAD/A board and asked for feedback.

“This came [to light] after a press release,” Dr. Bucay said in an interview. “I don’t have an issue with trying to improve and set the bar for what dermatology physician assistants should do. It’s the manner in which it was gone about. In this day and age, we have to disclose any potential conflicts of interest. If we all have to do that as members of the American Society of Dermatologic Surgery or members of the AAD when presenting for continuing medical education, then why would there not be the same standard for a board member to disclose a conflict of interest?”

Dr. Dinehart for his part said the board never gave him an opportunity to respond to its accusations or share his side of the story before initiating the removal vote.

“The board should not have been pressured by a vocal minority of the membership, rushed to judgment, and expedited a special removal vote less than 2 weeks after the board claims it first became aware of the formation of ABDPA,” he said in the interview. “The board should have ... evaluated the alleged conflict and provided me a reasonable opportunity to cure the alleged conflict as provided by the AAD/A’s conflict of interest rules. Had the board allowed me that opportunity, as required, this whole situation could have been resolved.”

Dr. Hruza, however, said the board’s actions came after reviewing evidence with Dr. Dinehart in private, which allowed him to make a statement and provided him a chance to answer questions from the board. He was also afforded several opportunities to resign, which he declined, Dr. Hruza said in the interview.

“I regret that we have been put in this difficult position and that the question must be put to the membership for a painful vote,” Dr. Hruza said. “The academy has a lot of important work to do to advocate for our members and our patients. This issue has been an unfortunate distraction from that important work.”

Daniel M. Siegel, MD, a New York–based dermatologist and former AAD president, said in an interview with Dermatology News that he plans to vote to keep Dr. Dinehart on the board. Dr. Dinehart has been a dedicated advocate for the specialty for more than 30 years and his recent misstep does not rise to the level of board removal, Dr. Siegel said. A social media environment that easily enables people to get fired up about almost any subject and quickly stoke anger in others contributed to overreaction of the situation, he added.

“In retrospect, it was not in the best interests of the AAD, but it was nothing criminal,” Dr. Siegel said in the interview. “He had a business idea, it got a lot negative feedback, and he did the right thing about it. Taking such an aggressive punitive approach for a transgression that was fairly minor is a bad precedent to set.”

Voting on Dr. Dinehart’s position opened on Oct. 21 and will close on Oct. 29. A removal decision requires a two-thirds vote by at least 10% of the voting membership.

agallegos@mdedge.com

Whether a board member for the American Academy of Dermatology and the AAD Association (AAD/A) violated his fiduciary duties by launching an organization that offered board certification to physician assistants (PAs) will soon be decided by AAD members.

In mid-October, the AAD/A board of directors unanimously agreed to present AAD members with a resolution to remove Scott M. Dinehart, MD, from his position on the board. AAD President George J. Hruza, MD, said Dr. Dinehart violated his duties when he became sole organizer of the American Board of Dermatology Physician Assistants (ABDPA), an organization that planned to offer board certification to PAs who work with dermatologists, according to a message from Dr. Hruza to members. The use of the words “American Board of Dermatology” in the ABDPA name created confusion to patients and threatened to undermine the value of ABD certification held by AAD/A fellows, Dr. Hruza said.

“Dr. Dinehart’s action to incorporate and organize the for-profit entity ABDPA, LLC., is in direct contradiction to the AAD’s Truth in Advertising and Professional Disclosure policy that states that practitioners should not advertise that they are board certified unless they are certified by an ABMS/AOA [American Board of Medical Specialties or American Osteopathic Association] medical board, such as the American Board of Dermatology,” Dr. Hruza said in an interview with Dermatology News. “This for-profit venture would enable physician assistants to advertise themselves as board certified. The [AAD/A] board in its unanimous decision deemed that the new ABDPA was set up to potentially mislead patients into thinking that physician assistants with this certification would have training and experience equivalent to an ABD-certified dermatologist. This is contrary to the AAD/A’s position on this matter. As such, Dr. Dinehart’s involvement in forming and organizing the ABDPA violated his fiduciary duty to act in the best interests of the AAD/A and to abide by AAD/A policies.”

In a letter to AAD members, Dr. Dinehart called the removal vote a “drastic measure” and said he has done nothing to justify dismissal from the AAD/A board. The ABDPA was intended to improve patient care by establishing certain educational, training, and professional standards for the growing number of physician assistants in dermatology, Dr. Dinehart wrote. That mission was not in conflict with AAD’s values, but rather, the ABDPA would have furthered AAD’s purpose “to promote the highest standards in allied health professionals and services as they relate to dermatology.”

After learning of the board’s concerns, Dr. Dinehart said he discontinued his relationship with the ABDPA and ensured its operations had ended out of respect for the academy. He believes the matter could have been handled much differently.

“I did not violate any bylaws,” Dr. Dinehart said in an interview with Dermatology News. “While I understand that there are certain members of the AAD that personally oppose the growing use of physician assistants in dermatology practices, it is a common practice among many AAD members, and it is not contrary to or detrimental to any of the purposes of the AAD.”

Dr. Dinehart contends he did not run afoul of the AAD/A’s position statement on Truth in Advertising and Professional Credential Disclosure because the statement pertains to AAD/A members and prohibits members from advertising board certifications by nonapproved boards. He emphasized that PAs are not members and said he would never represent or advertise a physician assistant as having a certification equivalent to a board-certified dermatologist or being capable of equivalent credentials.

In addition, he said his involvement with the new organization did not conflict with the AAD’s Practice of Dermatology: Protecting and Preserving Patient Safety and Quality Care position statement, which opposes the independent or unsupervised practice of dermatology procedures by nonphysicians.

“Neither the ADBPA nor the certification it intended to offer would have allowed physician assistants to engage in the independent or unsupervised practice of specific dermatology procedures, and any physician assistant who did so would be subject to the same repercussions that currently exist,” Dr. Dinehart said in the interview.

The ABDPA was formed legally at the end of September and announced its official launch on Oct. 7. The new organization immediately drew criticism from dermatologists and triggered an online petition that denounced the group and called for Dr Dinehart’s removal from the AAD/A board. The petition, started by an anonymous dermatologist, states Dr. Dinehart’s concurrent relationships with the AAD and the ABDPA represent a major conflict of interest. As of Oct. 24, the petition had collected 2,496 signatures.

Monica Madray, MD, a dermatologist based in Georgetown, Tex., who signed the petition, said the ABDPA further muddied the waters in an already confusing world of “providers” and non–dermatology boarded physicians practicing and advertising themselves as dermatologists.

“Patients truly don’t know the difference in training between physicians and midlevels, and by ‘board certifying’ PAs in dermatology, it gets much more confusing,” Dr. Madray said in an interview. “I also think there was a huge financial conflict of interest for Dr. Dinehart to start and run this board as he oversees many midlevels. Frankly, it didn’t pass the sniff test.”

Vivian Bucay, MD, a dermatologist based in San Antonio who signed the petition, said that, if Dr. Dinehart was interested in starting an organization such as the ABDPA, he should have first presented the idea to the AAD/A board and asked for feedback.

“This came [to light] after a press release,” Dr. Bucay said in an interview. “I don’t have an issue with trying to improve and set the bar for what dermatology physician assistants should do. It’s the manner in which it was gone about. In this day and age, we have to disclose any potential conflicts of interest. If we all have to do that as members of the American Society of Dermatologic Surgery or members of the AAD when presenting for continuing medical education, then why would there not be the same standard for a board member to disclose a conflict of interest?”

Dr. Dinehart for his part said the board never gave him an opportunity to respond to its accusations or share his side of the story before initiating the removal vote.

“The board should not have been pressured by a vocal minority of the membership, rushed to judgment, and expedited a special removal vote less than 2 weeks after the board claims it first became aware of the formation of ABDPA,” he said in the interview. “The board should have ... evaluated the alleged conflict and provided me a reasonable opportunity to cure the alleged conflict as provided by the AAD/A’s conflict of interest rules. Had the board allowed me that opportunity, as required, this whole situation could have been resolved.”

Dr. Hruza, however, said the board’s actions came after reviewing evidence with Dr. Dinehart in private, which allowed him to make a statement and provided him a chance to answer questions from the board. He was also afforded several opportunities to resign, which he declined, Dr. Hruza said in the interview.

“I regret that we have been put in this difficult position and that the question must be put to the membership for a painful vote,” Dr. Hruza said. “The academy has a lot of important work to do to advocate for our members and our patients. This issue has been an unfortunate distraction from that important work.”

Daniel M. Siegel, MD, a New York–based dermatologist and former AAD president, said in an interview with Dermatology News that he plans to vote to keep Dr. Dinehart on the board. Dr. Dinehart has been a dedicated advocate for the specialty for more than 30 years and his recent misstep does not rise to the level of board removal, Dr. Siegel said. A social media environment that easily enables people to get fired up about almost any subject and quickly stoke anger in others contributed to overreaction of the situation, he added.

“In retrospect, it was not in the best interests of the AAD, but it was nothing criminal,” Dr. Siegel said in the interview. “He had a business idea, it got a lot negative feedback, and he did the right thing about it. Taking such an aggressive punitive approach for a transgression that was fairly minor is a bad precedent to set.”

Voting on Dr. Dinehart’s position opened on Oct. 21 and will close on Oct. 29. A removal decision requires a two-thirds vote by at least 10% of the voting membership.

agallegos@mdedge.com

Whether a board member for the American Academy of Dermatology and the AAD Association (AAD/A) violated his fiduciary duties by launching an organization that offered board certification to physician assistants (PAs) will soon be decided by AAD members.

In mid-October, the AAD/A board of directors unanimously agreed to present AAD members with a resolution to remove Scott M. Dinehart, MD, from his position on the board. AAD President George J. Hruza, MD, said Dr. Dinehart violated his duties when he became sole organizer of the American Board of Dermatology Physician Assistants (ABDPA), an organization that planned to offer board certification to PAs who work with dermatologists, according to a message from Dr. Hruza to members. The use of the words “American Board of Dermatology” in the ABDPA name created confusion to patients and threatened to undermine the value of ABD certification held by AAD/A fellows, Dr. Hruza said.

“Dr. Dinehart’s action to incorporate and organize the for-profit entity ABDPA, LLC., is in direct contradiction to the AAD’s Truth in Advertising and Professional Disclosure policy that states that practitioners should not advertise that they are board certified unless they are certified by an ABMS/AOA [American Board of Medical Specialties or American Osteopathic Association] medical board, such as the American Board of Dermatology,” Dr. Hruza said in an interview with Dermatology News. “This for-profit venture would enable physician assistants to advertise themselves as board certified. The [AAD/A] board in its unanimous decision deemed that the new ABDPA was set up to potentially mislead patients into thinking that physician assistants with this certification would have training and experience equivalent to an ABD-certified dermatologist. This is contrary to the AAD/A’s position on this matter. As such, Dr. Dinehart’s involvement in forming and organizing the ABDPA violated his fiduciary duty to act in the best interests of the AAD/A and to abide by AAD/A policies.”

In a letter to AAD members, Dr. Dinehart called the removal vote a “drastic measure” and said he has done nothing to justify dismissal from the AAD/A board. The ABDPA was intended to improve patient care by establishing certain educational, training, and professional standards for the growing number of physician assistants in dermatology, Dr. Dinehart wrote. That mission was not in conflict with AAD’s values, but rather, the ABDPA would have furthered AAD’s purpose “to promote the highest standards in allied health professionals and services as they relate to dermatology.”

After learning of the board’s concerns, Dr. Dinehart said he discontinued his relationship with the ABDPA and ensured its operations had ended out of respect for the academy. He believes the matter could have been handled much differently.

“I did not violate any bylaws,” Dr. Dinehart said in an interview with Dermatology News. “While I understand that there are certain members of the AAD that personally oppose the growing use of physician assistants in dermatology practices, it is a common practice among many AAD members, and it is not contrary to or detrimental to any of the purposes of the AAD.”

Dr. Dinehart contends he did not run afoul of the AAD/A’s position statement on Truth in Advertising and Professional Credential Disclosure because the statement pertains to AAD/A members and prohibits members from advertising board certifications by nonapproved boards. He emphasized that PAs are not members and said he would never represent or advertise a physician assistant as having a certification equivalent to a board-certified dermatologist or being capable of equivalent credentials.

In addition, he said his involvement with the new organization did not conflict with the AAD’s Practice of Dermatology: Protecting and Preserving Patient Safety and Quality Care position statement, which opposes the independent or unsupervised practice of dermatology procedures by nonphysicians.

“Neither the ADBPA nor the certification it intended to offer would have allowed physician assistants to engage in the independent or unsupervised practice of specific dermatology procedures, and any physician assistant who did so would be subject to the same repercussions that currently exist,” Dr. Dinehart said in the interview.

The ABDPA was formed legally at the end of September and announced its official launch on Oct. 7. The new organization immediately drew criticism from dermatologists and triggered an online petition that denounced the group and called for Dr Dinehart’s removal from the AAD/A board. The petition, started by an anonymous dermatologist, states Dr. Dinehart’s concurrent relationships with the AAD and the ABDPA represent a major conflict of interest. As of Oct. 24, the petition had collected 2,496 signatures.

Monica Madray, MD, a dermatologist based in Georgetown, Tex., who signed the petition, said the ABDPA further muddied the waters in an already confusing world of “providers” and non–dermatology boarded physicians practicing and advertising themselves as dermatologists.

“Patients truly don’t know the difference in training between physicians and midlevels, and by ‘board certifying’ PAs in dermatology, it gets much more confusing,” Dr. Madray said in an interview. “I also think there was a huge financial conflict of interest for Dr. Dinehart to start and run this board as he oversees many midlevels. Frankly, it didn’t pass the sniff test.”

Vivian Bucay, MD, a dermatologist based in San Antonio who signed the petition, said that, if Dr. Dinehart was interested in starting an organization such as the ABDPA, he should have first presented the idea to the AAD/A board and asked for feedback.

“This came [to light] after a press release,” Dr. Bucay said in an interview. “I don’t have an issue with trying to improve and set the bar for what dermatology physician assistants should do. It’s the manner in which it was gone about. In this day and age, we have to disclose any potential conflicts of interest. If we all have to do that as members of the American Society of Dermatologic Surgery or members of the AAD when presenting for continuing medical education, then why would there not be the same standard for a board member to disclose a conflict of interest?”

Dr. Dinehart for his part said the board never gave him an opportunity to respond to its accusations or share his side of the story before initiating the removal vote.

“The board should not have been pressured by a vocal minority of the membership, rushed to judgment, and expedited a special removal vote less than 2 weeks after the board claims it first became aware of the formation of ABDPA,” he said in the interview. “The board should have ... evaluated the alleged conflict and provided me a reasonable opportunity to cure the alleged conflict as provided by the AAD/A’s conflict of interest rules. Had the board allowed me that opportunity, as required, this whole situation could have been resolved.”

Dr. Hruza, however, said the board’s actions came after reviewing evidence with Dr. Dinehart in private, which allowed him to make a statement and provided him a chance to answer questions from the board. He was also afforded several opportunities to resign, which he declined, Dr. Hruza said in the interview.

“I regret that we have been put in this difficult position and that the question must be put to the membership for a painful vote,” Dr. Hruza said. “The academy has a lot of important work to do to advocate for our members and our patients. This issue has been an unfortunate distraction from that important work.”

Daniel M. Siegel, MD, a New York–based dermatologist and former AAD president, said in an interview with Dermatology News that he plans to vote to keep Dr. Dinehart on the board. Dr. Dinehart has been a dedicated advocate for the specialty for more than 30 years and his recent misstep does not rise to the level of board removal, Dr. Siegel said. A social media environment that easily enables people to get fired up about almost any subject and quickly stoke anger in others contributed to overreaction of the situation, he added.

“In retrospect, it was not in the best interests of the AAD, but it was nothing criminal,” Dr. Siegel said in the interview. “He had a business idea, it got a lot negative feedback, and he did the right thing about it. Taking such an aggressive punitive approach for a transgression that was fairly minor is a bad precedent to set.”

Voting on Dr. Dinehart’s position opened on Oct. 21 and will close on Oct. 29. A removal decision requires a two-thirds vote by at least 10% of the voting membership.

agallegos@mdedge.com

The Trump administration apparently plans to ensure Americans have access to health insurance in the event that the Affordable Care Act is struck down – but officials refuse to share that plan.

“The president has made clear that we will have a plan in action to make sure that Americans have access to affordable coverage” if or when courts negate the ACA, Seema Verma, administrator of the Centers for Medicare & Medicaid Services said Oct. 23 at a House Ways and Means Health Subcommittee hearing. “We do not have that today. There are many Americans today, they are not getting a subsidy. They can’t afford insurance today.”

When asked specifically about the provision to guarantee coverage for those with preexisting conditions, Ms. Verma replied that the president “has made clear that we will do everything we can to ensure that Americans with preexisting conditions maintain the protection that they have today.”

When pressed for details, Ms. Verma dodged the question, first by attempting to tell an anecdote about “a 55-year-old couple making $66,000 a year ...” before getting cut off. When the question was reiterated by Health Subcommittee Chair Diana DeGette (D-Colo.), Ms. Verma replied, “I am not going get into any specifics of a plan.”

Committee Chair Frank Pallone (D-N.J.) said it was “deceptive” that Ms. Verma would not provide any details and openly questioned whether a plan actually existed.

The hearing followed a partisan pattern.

Republican subcommittee members asked questions that allowed Ms Verma to highlight some of the actions taken by the CMS under her watch, such as lowering premiums for exchange plans, increasing the number of available plans and decreasing the number of states that had only one plan option available in the exchange, and other items that are focused on lowering the cost of health care.

“We’re trying to focus on actions that lower the cost of care for Americans,” she said. “If we do that, more people will be able to afford health care.”

Under questioning by panel Democrats, Ms. Verma took a more adversarial tone and tended to deflect rather than answer questions.

When pressed about Medicaid work requirement and the disruption in health care coverage they are causing, Ms. Verma had no answer, instead trying to talking about “community engagement requirements” before being cut off.

Ms. Verma also refused to address the coverage requirements, or lack thereof, of short-term, limited duration plans, which have been expanded under the Trump administration.

When asked whether plans could deny claims based on preexisting conditions, could implement coverage caps, charge more based on age or gender, or ignore other consumer protections in the ACA, she consistently defaulted to a comment that it “depends” on the plan and what they offer, without coming out and simply acknowledging that these plans have it within their power to ignore any and all consumer protections held within the Affordable Care Act.

“None of the actions that we have taken do anything to undermine the protections for people with preexisting conditions,” she said.

“Your testimony is not actually truthful to us today,” Rep. Ann Kuster (D-N.H.) replied.

gtwachtman@mdedge.com

The Trump administration apparently plans to ensure Americans have access to health insurance in the event that the Affordable Care Act is struck down – but officials refuse to share that plan.

“The president has made clear that we will have a plan in action to make sure that Americans have access to affordable coverage” if or when courts negate the ACA, Seema Verma, administrator of the Centers for Medicare & Medicaid Services said Oct. 23 at a House Ways and Means Health Subcommittee hearing. “We do not have that today. There are many Americans today, they are not getting a subsidy. They can’t afford insurance today.”

When asked specifically about the provision to guarantee coverage for those with preexisting conditions, Ms. Verma replied that the president “has made clear that we will do everything we can to ensure that Americans with preexisting conditions maintain the protection that they have today.”

When pressed for details, Ms. Verma dodged the question, first by attempting to tell an anecdote about “a 55-year-old couple making $66,000 a year ...” before getting cut off. When the question was reiterated by Health Subcommittee Chair Diana DeGette (D-Colo.), Ms. Verma replied, “I am not going get into any specifics of a plan.”

Committee Chair Frank Pallone (D-N.J.) said it was “deceptive” that Ms. Verma would not provide any details and openly questioned whether a plan actually existed.

The hearing followed a partisan pattern.

Republican subcommittee members asked questions that allowed Ms Verma to highlight some of the actions taken by the CMS under her watch, such as lowering premiums for exchange plans, increasing the number of available plans and decreasing the number of states that had only one plan option available in the exchange, and other items that are focused on lowering the cost of health care.

“We’re trying to focus on actions that lower the cost of care for Americans,” she said. “If we do that, more people will be able to afford health care.”

Under questioning by panel Democrats, Ms. Verma took a more adversarial tone and tended to deflect rather than answer questions.

When pressed about Medicaid work requirement and the disruption in health care coverage they are causing, Ms. Verma had no answer, instead trying to talking about “community engagement requirements” before being cut off.

Ms. Verma also refused to address the coverage requirements, or lack thereof, of short-term, limited duration plans, which have been expanded under the Trump administration.

When asked whether plans could deny claims based on preexisting conditions, could implement coverage caps, charge more based on age or gender, or ignore other consumer protections in the ACA, she consistently defaulted to a comment that it “depends” on the plan and what they offer, without coming out and simply acknowledging that these plans have it within their power to ignore any and all consumer protections held within the Affordable Care Act.

“None of the actions that we have taken do anything to undermine the protections for people with preexisting conditions,” she said.

“Your testimony is not actually truthful to us today,” Rep. Ann Kuster (D-N.H.) replied.

gtwachtman@mdedge.com

The Trump administration apparently plans to ensure Americans have access to health insurance in the event that the Affordable Care Act is struck down – but officials refuse to share that plan.

“The president has made clear that we will have a plan in action to make sure that Americans have access to affordable coverage” if or when courts negate the ACA, Seema Verma, administrator of the Centers for Medicare & Medicaid Services said Oct. 23 at a House Ways and Means Health Subcommittee hearing. “We do not have that today. There are many Americans today, they are not getting a subsidy. They can’t afford insurance today.”

When asked specifically about the provision to guarantee coverage for those with preexisting conditions, Ms. Verma replied that the president “has made clear that we will do everything we can to ensure that Americans with preexisting conditions maintain the protection that they have today.”

When pressed for details, Ms. Verma dodged the question, first by attempting to tell an anecdote about “a 55-year-old couple making $66,000 a year ...” before getting cut off. When the question was reiterated by Health Subcommittee Chair Diana DeGette (D-Colo.), Ms. Verma replied, “I am not going get into any specifics of a plan.”

Committee Chair Frank Pallone (D-N.J.) said it was “deceptive” that Ms. Verma would not provide any details and openly questioned whether a plan actually existed.

The hearing followed a partisan pattern.

Republican subcommittee members asked questions that allowed Ms Verma to highlight some of the actions taken by the CMS under her watch, such as lowering premiums for exchange plans, increasing the number of available plans and decreasing the number of states that had only one plan option available in the exchange, and other items that are focused on lowering the cost of health care.

“We’re trying to focus on actions that lower the cost of care for Americans,” she said. “If we do that, more people will be able to afford health care.”

Under questioning by panel Democrats, Ms. Verma took a more adversarial tone and tended to deflect rather than answer questions.

When pressed about Medicaid work requirement and the disruption in health care coverage they are causing, Ms. Verma had no answer, instead trying to talking about “community engagement requirements” before being cut off.

Ms. Verma also refused to address the coverage requirements, or lack thereof, of short-term, limited duration plans, which have been expanded under the Trump administration.

When asked whether plans could deny claims based on preexisting conditions, could implement coverage caps, charge more based on age or gender, or ignore other consumer protections in the ACA, she consistently defaulted to a comment that it “depends” on the plan and what they offer, without coming out and simply acknowledging that these plans have it within their power to ignore any and all consumer protections held within the Affordable Care Act.

“None of the actions that we have taken do anything to undermine the protections for people with preexisting conditions,” she said.

“Your testimony is not actually truthful to us today,” Rep. Ann Kuster (D-N.H.) replied.

gtwachtman@mdedge.com

The House Ways and Means Committee is the latest to pass H.R. 3, a bill aimed at driving the price of prescription drugs down.

©Mathier/thinkstockphotos.com

During an Oct. 22, 2019, markup of the bill, Republican members criticized committee leadership for abandoning bipartisan efforts to reign in drug prices in favor of a partisan bill that so far gained no support from the minority party. H.R. 3 was passed by the Ways and Means Committee on a 24-17 party line vote.

Both “Democrats and Republicans support lowering drug prices, cracking down on overpriced drugs, giving patients more power to choose affordable medicines, and removing the wrong incentives in federal health programs that reward bad actors for raising prices,” Committee Ranking Member Kevin Brady (R-Tex.) said in his opening statement. In fact, at the request of Committee Chairman Richard Neal (D-Mass.), “both parties in this committee were working together toward that important goal. At least until Speaker Nancy Pelosi (D-Calif.) trashed the bipartisan work and forced through a secretly written, deeply controversial, and highly partisan drug bill to cure political illnesses rather than real ones.”

H.R. 3, recently renamed the Elijah E. Cummings Lower Drug Costs Now Act of 2019, would give the secretary of the Department of Health & Human Services the ability to negotiate drug prices for Medicare Part D (something explicitly banned under current law), implement an excise tax on drugs that see price hikes above the rate of inflation, cap out-of-pocket expenditures annually for Medicare Part D beneficiaries at $2,000, and use an international pricing index to help bring prices for drugs sold in the United States more in line with the lower prices in foreign countries.

But panel Democrats praised the bill as a step forward in helping to lower the cost of prescription drugs.

“H.R. 3 levels the playing field for U.S. consumers who, on average, pay four times more than patients in other countries for the exact same drugs,” Chairman Neal said in a statement following the passage.

He highlighted specifically the provision that caps out-of-pocket expenses in Part D and the HHS’ negotiating power, noting that “more people will be able to afford the drugs they need that they may have previously forgone due to high costs. With more Americans taking the medicines they’re prescribed, families will be healthier, and premiums will go down.”

Republican committee members argued that these same provisions would stifle innovation and ultimately would reduce access to medicine. Most attempts at altering the provisions through amendments were met with strict party line rejection.

gtwachtman@mdedge.com

The House Ways and Means Committee is the latest to pass H.R. 3, a bill aimed at driving the price of prescription drugs down.

©Mathier/thinkstockphotos.com

During an Oct. 22, 2019, markup of the bill, Republican members criticized committee leadership for abandoning bipartisan efforts to reign in drug prices in favor of a partisan bill that so far gained no support from the minority party. H.R. 3 was passed by the Ways and Means Committee on a 24-17 party line vote.

Both “Democrats and Republicans support lowering drug prices, cracking down on overpriced drugs, giving patients more power to choose affordable medicines, and removing the wrong incentives in federal health programs that reward bad actors for raising prices,” Committee Ranking Member Kevin Brady (R-Tex.) said in his opening statement. In fact, at the request of Committee Chairman Richard Neal (D-Mass.), “both parties in this committee were working together toward that important goal. At least until Speaker Nancy Pelosi (D-Calif.) trashed the bipartisan work and forced through a secretly written, deeply controversial, and highly partisan drug bill to cure political illnesses rather than real ones.”

H.R. 3, recently renamed the Elijah E. Cummings Lower Drug Costs Now Act of 2019, would give the secretary of the Department of Health & Human Services the ability to negotiate drug prices for Medicare Part D (something explicitly banned under current law), implement an excise tax on drugs that see price hikes above the rate of inflation, cap out-of-pocket expenditures annually for Medicare Part D beneficiaries at $2,000, and use an international pricing index to help bring prices for drugs sold in the United States more in line with the lower prices in foreign countries.

But panel Democrats praised the bill as a step forward in helping to lower the cost of prescription drugs.

“H.R. 3 levels the playing field for U.S. consumers who, on average, pay four times more than patients in other countries for the exact same drugs,” Chairman Neal said in a statement following the passage.

He highlighted specifically the provision that caps out-of-pocket expenses in Part D and the HHS’ negotiating power, noting that “more people will be able to afford the drugs they need that they may have previously forgone due to high costs. With more Americans taking the medicines they’re prescribed, families will be healthier, and premiums will go down.”

Republican committee members argued that these same provisions would stifle innovation and ultimately would reduce access to medicine. Most attempts at altering the provisions through amendments were met with strict party line rejection.

gtwachtman@mdedge.com

The House Ways and Means Committee is the latest to pass H.R. 3, a bill aimed at driving the price of prescription drugs down.

©Mathier/thinkstockphotos.com

During an Oct. 22, 2019, markup of the bill, Republican members criticized committee leadership for abandoning bipartisan efforts to reign in drug prices in favor of a partisan bill that so far gained no support from the minority party. H.R. 3 was passed by the Ways and Means Committee on a 24-17 party line vote.

Both “Democrats and Republicans support lowering drug prices, cracking down on overpriced drugs, giving patients more power to choose affordable medicines, and removing the wrong incentives in federal health programs that reward bad actors for raising prices,” Committee Ranking Member Kevin Brady (R-Tex.) said in his opening statement. In fact, at the request of Committee Chairman Richard Neal (D-Mass.), “both parties in this committee were working together toward that important goal. At least until Speaker Nancy Pelosi (D-Calif.) trashed the bipartisan work and forced through a secretly written, deeply controversial, and highly partisan drug bill to cure political illnesses rather than real ones.”

H.R. 3, recently renamed the Elijah E. Cummings Lower Drug Costs Now Act of 2019, would give the secretary of the Department of Health & Human Services the ability to negotiate drug prices for Medicare Part D (something explicitly banned under current law), implement an excise tax on drugs that see price hikes above the rate of inflation, cap out-of-pocket expenditures annually for Medicare Part D beneficiaries at $2,000, and use an international pricing index to help bring prices for drugs sold in the United States more in line with the lower prices in foreign countries.

But panel Democrats praised the bill as a step forward in helping to lower the cost of prescription drugs.

“H.R. 3 levels the playing field for U.S. consumers who, on average, pay four times more than patients in other countries for the exact same drugs,” Chairman Neal said in a statement following the passage.

He highlighted specifically the provision that caps out-of-pocket expenses in Part D and the HHS’ negotiating power, noting that “more people will be able to afford the drugs they need that they may have previously forgone due to high costs. With more Americans taking the medicines they’re prescribed, families will be healthier, and premiums will go down.”

Republican committee members argued that these same provisions would stifle innovation and ultimately would reduce access to medicine. Most attempts at altering the provisions through amendments were met with strict party line rejection.

gtwachtman@mdedge.com

“Why didn’t you see that patient?”

TongRo Images/Thinkstock

The hospitalist on the phone was angry. He’d wanted the patient seen by neurology and cleared for discharge. Apparently, I hadn’t complied.

Actually, that isn’t true. I was on call, so I had dutifully dragged myself in (with the help of some coffee), reviewed the chart, and gone in to see the fellow.

The patient, however, had other ideas. He said he was sick of doctors, didn’t like them, didn’t want to see me, and asked me to leave. So I did.

This threw off the hospitalist’s well-choreographed day of admissions and discharges. Without me seeing the patient, he had to either discharge him on his own decision or find another neurologist who would do it.

Sorry, but I’m not going to force this issue. If a patient doesn’t want to see me, it’s not worth fighting over. Believe me, I get paid to see patients, so I don’t have much incentive to just walk away.

But at the same time I have to respect patients’ decisions. While a neurology consult is pretty noninvasive, it’s still a part of medicine. If a patient doesn’t want to see me, I’m not going to force them to.

Granted, there are exceptions. Obviously, if the patient is fairly demented or otherwise not mentally competent to make such a decision, I’ll see them. In those cases, their deteriorating mental status is likely the reason for the consult.

But the fellow that day seemed alert and reasonable, and there was nothing in the chart about confusion. So I’m going to assume he knew what he was doing when he told me to go away.

The hospitalist didn’t see this as an issue, but I did. Doing a consult on a patient who doesn’t want one seems, at least to me, like harassment. I’m sorry if it messes up the discharge planning, but that’s not my fault. It’s the patient’s decision.

While I may disagree at times with patients’ decisions, their autonomy is still central to medicine. I respect and believe in that, even if it makes things more difficult for those around them.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

“Why didn’t you see that patient?”

TongRo Images/Thinkstock

The hospitalist on the phone was angry. He’d wanted the patient seen by neurology and cleared for discharge. Apparently, I hadn’t complied.

Actually, that isn’t true. I was on call, so I had dutifully dragged myself in (with the help of some coffee), reviewed the chart, and gone in to see the fellow.

The patient, however, had other ideas. He said he was sick of doctors, didn’t like them, didn’t want to see me, and asked me to leave. So I did.

This threw off the hospitalist’s well-choreographed day of admissions and discharges. Without me seeing the patient, he had to either discharge him on his own decision or find another neurologist who would do it.

Sorry, but I’m not going to force this issue. If a patient doesn’t want to see me, it’s not worth fighting over. Believe me, I get paid to see patients, so I don’t have much incentive to just walk away.

But at the same time I have to respect patients’ decisions. While a neurology consult is pretty noninvasive, it’s still a part of medicine. If a patient doesn’t want to see me, I’m not going to force them to.

Granted, there are exceptions. Obviously, if the patient is fairly demented or otherwise not mentally competent to make such a decision, I’ll see them. In those cases, their deteriorating mental status is likely the reason for the consult.

But the fellow that day seemed alert and reasonable, and there was nothing in the chart about confusion. So I’m going to assume he knew what he was doing when he told me to go away.

The hospitalist didn’t see this as an issue, but I did. Doing a consult on a patient who doesn’t want one seems, at least to me, like harassment. I’m sorry if it messes up the discharge planning, but that’s not my fault. It’s the patient’s decision.

While I may disagree at times with patients’ decisions, their autonomy is still central to medicine. I respect and believe in that, even if it makes things more difficult for those around them.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

“Why didn’t you see that patient?”

TongRo Images/Thinkstock

The hospitalist on the phone was angry. He’d wanted the patient seen by neurology and cleared for discharge. Apparently, I hadn’t complied.

Actually, that isn’t true. I was on call, so I had dutifully dragged myself in (with the help of some coffee), reviewed the chart, and gone in to see the fellow.

The patient, however, had other ideas. He said he was sick of doctors, didn’t like them, didn’t want to see me, and asked me to leave. So I did.

This threw off the hospitalist’s well-choreographed day of admissions and discharges. Without me seeing the patient, he had to either discharge him on his own decision or find another neurologist who would do it.

Sorry, but I’m not going to force this issue. If a patient doesn’t want to see me, it’s not worth fighting over. Believe me, I get paid to see patients, so I don’t have much incentive to just walk away.

But at the same time I have to respect patients’ decisions. While a neurology consult is pretty noninvasive, it’s still a part of medicine. If a patient doesn’t want to see me, I’m not going to force them to.

Granted, there are exceptions. Obviously, if the patient is fairly demented or otherwise not mentally competent to make such a decision, I’ll see them. In those cases, their deteriorating mental status is likely the reason for the consult.

But the fellow that day seemed alert and reasonable, and there was nothing in the chart about confusion. So I’m going to assume he knew what he was doing when he told me to go away.

The hospitalist didn’t see this as an issue, but I did. Doing a consult on a patient who doesn’t want one seems, at least to me, like harassment. I’m sorry if it messes up the discharge planning, but that’s not my fault. It’s the patient’s decision.

While I may disagree at times with patients’ decisions, their autonomy is still central to medicine. I respect and believe in that, even if it makes things more difficult for those around them.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Rheumatology drugs, like most drugs, are seeing significant price hikes in recent years and, according to a new analysis, those hikes account for the majority of growth in spending.

From 2012 to 2016, annual spending on public-payer claims for 10 biologic disease-modifying antirheumatic drugs (bDMARDs) more than doubled (from $3.8 billion to $8.6 billion), with median drug price increases of 51% in the Medicare Part D prescription drug plans (mean, 54%) and 8% within Medicare Part B drugs administered within the physician office (mean, 21%).

“The prominent bDMARD drug cost increases observed in this study, which were substantially greater under Part D than Part B, even when accounting for rebates, represent a growing burden to taxpayers and beneficiaries,” first author Natalie McCormick, PhD, a research fellow at Massachusetts General Hospital, Boston, and colleagues wrote in Arthritis & Rheumatology.

“The magnitude of these increases is independent from any assessment of value,” the authors continued.

Dr. McCormick and colleagues highlighted the limited effect that rebates negotiated by pharmacy benefit managers (PBMs) for Part D have on patient out-of-pocket costs.

Negotiations “may not necessarily result in lower price increases since pharmacy benefit managers, who negotiate on behalf of Part D plans, retain a percentage of the negotiated rebates as compensation, and higher list prices can achieve higher rebates,” they stated. “While these rebates accrue to insurance plans and pharmacy benefit managers, they do not directly impact Part D beneficiaries’ out-of-pocket costs, which are driven by prerebate prices. Thus, many patients end up paying higher out-of-pocket costs when the list price increases, creating financial barriers to use and adherence.”

They further noted that, for most Part D drugs individually, “drug prices accounted for approximately 50% or more of the increase in spending. Adalimumab and etanercept, two of the oldest bDMARDs, were prescribed to the largest number of Part D beneficiaries (more than 47,000 in 2016) and had the biggest 5-year price increases: 84% and 88%, respectively (72% and 75% respectively, accounting for rebates).”

It is not surprising that the analysis found that prices are rising and are a driving force in spending.

“We know that high launch prices of a new drug is an important consideration for patient access,” Jeromie Ballreich, PhD, a health economist at Johns Hopkins University, Baltimore, said in an interview. “But we also know that a number of these drugs, particularly Humira and Enbrel, have been on the market for a while. They have experienced a tremendous price increase over the past 10 years plus. That’s exactly what the authors found. So that is really not surprising. Analysis of drug spending changes over the time [shows that] it is indeed price increases that really have been driving increases in drug spending.”

Angus Worthing, MD, a rheumatologist at Arthritis & Rheumatism Associates in Washington, D.C., and current chair of the American College of Rheumatology’s Government Affairs Committee, said that the faster price hikes in Part D stood out in the analysis and the role PBMs played in it.

“I was a little surprised at just how much more PBMs were responsible for higher inflation, compared to the part B system,” he said in an interview. “In the McCormick article, drug prices went up 45% after rebates in the Part D space, but only 21% in the Part B space, and we had seen hints that drug prices were going up faster, we just didn’t know just how much faster, so more than double the increase is more than I expected, and it is very concerning to look at that and realize that PBMs are more than doubling an already high inflation rate in drug prices.”

He suggested that part of the rise in Part D bDMARD prices observed in the study might be because of the application of step therapy in Part D.

“In Medicare specifically, step therapy is allowed in Part D but not in Part B – except in Medicare Advantage plans starting in 2019 – and this important difference between Part B and Part D explains how Part D rebates, linked with step therapy, may be the main reason that bDMARD prices rose more in Part D compared to the open formulary system in Medicare Part B,” Dr. Worthing wrote in an editorial on Dr. McCormick’s study.

The Pharmaceutical Care Management Association, the lobby group representing PBMs, declined an interview request, but challenged the analysis’ portrayal of the role of PBMs in an email. It pointed to a Government Accountability Organization report from July 2019 that found that Part D rebates helped offset spending by about 20% and that PBM compensation was primarily derived from administrative fees and not from maintaining a portion of rebates that the PBM negotiated on behalf of the plan.

Dr. Worthing said in an interview that these bDMARD price hikes are causing access issues, particularly in Medicare where beneficiaries cannot take advantage of manufacturer programs, such as discount cards and copay coupons, and potentially face coinsurance payments based on the list price and not the net-of-rebate price.

From a policy standpoint, he advocated for a cap on out-of-pocket spending for Medicare Part D drugs, which is a feature of legislation (H.R. 3, Lower Drug Costs Now Act of 2019) that is moving through the House of Representatives, most recently passing the House Ways and Means Committee in a party-line vote of 24-17, with 1 Democrat not voting.

Dr. Worthing’s editorial covers a few other policy options, including more financial transparency in the role PBMs play in the drug supply chain, the elimination of rebates in favor of a flat fee for PBMs or requiring all rebates on drugs to be passed through to Part D beneficiaries, penalties on manufacturers for price increases that exceed inflation, and usage of a price index based on what foreign countries pay for the same drug.

Many of the suggestions from Dr. Worthing’s editorial are in H.R. 3 and face an uphill battle to get through the Senate.

Dr. Worthing said that tackling the rebate issue by removing incentives for manufacturers to raise prices in order to offer higher rebates and changing step-therapy rules are things Congress could probably get accomplished as it heads into an election year, but there is a chance it could be even more comprehensive.

“With such an important issue like high drug prices, it probably benefits both parties, and everybody facing an election will be able to go back to their constituents and say, ‘Look we got something done. I was part of this,’ and there is a better chance they will do it if they hear about it from their constituents,” he said.

Dr. Ballreich was less optimistic that H.R. 3 is going to be able to survive.

“The interesting thing with this bill is that a number of pieces of it have been endorsed by President Trump, and the question is, [is] that a meaningful endorsement? Is the Trump administration going to want to use the this plan as a win for him, as a win for showing potential voters that he can work in a bipartisan way, [that] he could take on ‘big drug companies’ – all those successful soundbites? Can then Trump use his power to push this bill through the Senate? I think that is a question mark,” he said, noting that it could take a lot of political capital to counter the powerful industry lobby. Ultimately, he expects that, if drug pricing does make it to the White House, it will go through some changes from where H.R. 3 is right now.

“I don’t think it will pass in its current iteration,” he said.

Each author of Dr. McCormick’s report had funding from different sources, though the funders had no role in the design and conduct of the study. No other disclosures were made.

gtwachtman@mdedge.com

SOURCES: McCormick N et al. Arthritis Rheumatol. 2019 Oct 14. doi: 10.1002/ART.41138; Worthing A. Arthritis Rheumatol. 2019 Oct 14. doi: 10.1002/art.41135.

Rheumatology drugs, like most drugs, are seeing significant price hikes in recent years and, according to a new analysis, those hikes account for the majority of growth in spending.

From 2012 to 2016, annual spending on public-payer claims for 10 biologic disease-modifying antirheumatic drugs (bDMARDs) more than doubled (from $3.8 billion to $8.6 billion), with median drug price increases of 51% in the Medicare Part D prescription drug plans (mean, 54%) and 8% within Medicare Part B drugs administered within the physician office (mean, 21%).

“The prominent bDMARD drug cost increases observed in this study, which were substantially greater under Part D than Part B, even when accounting for rebates, represent a growing burden to taxpayers and beneficiaries,” first author Natalie McCormick, PhD, a research fellow at Massachusetts General Hospital, Boston, and colleagues wrote in Arthritis & Rheumatology.

“The magnitude of these increases is independent from any assessment of value,” the authors continued.

Dr. McCormick and colleagues highlighted the limited effect that rebates negotiated by pharmacy benefit managers (PBMs) for Part D have on patient out-of-pocket costs.

Negotiations “may not necessarily result in lower price increases since pharmacy benefit managers, who negotiate on behalf of Part D plans, retain a percentage of the negotiated rebates as compensation, and higher list prices can achieve higher rebates,” they stated. “While these rebates accrue to insurance plans and pharmacy benefit managers, they do not directly impact Part D beneficiaries’ out-of-pocket costs, which are driven by prerebate prices. Thus, many patients end up paying higher out-of-pocket costs when the list price increases, creating financial barriers to use and adherence.”

They further noted that, for most Part D drugs individually, “drug prices accounted for approximately 50% or more of the increase in spending. Adalimumab and etanercept, two of the oldest bDMARDs, were prescribed to the largest number of Part D beneficiaries (more than 47,000 in 2016) and had the biggest 5-year price increases: 84% and 88%, respectively (72% and 75% respectively, accounting for rebates).”

It is not surprising that the analysis found that prices are rising and are a driving force in spending.

“We know that high launch prices of a new drug is an important consideration for patient access,” Jeromie Ballreich, PhD, a health economist at Johns Hopkins University, Baltimore, said in an interview. “But we also know that a number of these drugs, particularly Humira and Enbrel, have been on the market for a while. They have experienced a tremendous price increase over the past 10 years plus. That’s exactly what the authors found. So that is really not surprising. Analysis of drug spending changes over the time [shows that] it is indeed price increases that really have been driving increases in drug spending.”

Angus Worthing, MD, a rheumatologist at Arthritis & Rheumatism Associates in Washington, D.C., and current chair of the American College of Rheumatology’s Government Affairs Committee, said that the faster price hikes in Part D stood out in the analysis and the role PBMs played in it.

“I was a little surprised at just how much more PBMs were responsible for higher inflation, compared to the part B system,” he said in an interview. “In the McCormick article, drug prices went up 45% after rebates in the Part D space, but only 21% in the Part B space, and we had seen hints that drug prices were going up faster, we just didn’t know just how much faster, so more than double the increase is more than I expected, and it is very concerning to look at that and realize that PBMs are more than doubling an already high inflation rate in drug prices.”

He suggested that part of the rise in Part D bDMARD prices observed in the study might be because of the application of step therapy in Part D.

“In Medicare specifically, step therapy is allowed in Part D but not in Part B – except in Medicare Advantage plans starting in 2019 – and this important difference between Part B and Part D explains how Part D rebates, linked with step therapy, may be the main reason that bDMARD prices rose more in Part D compared to the open formulary system in Medicare Part B,” Dr. Worthing wrote in an editorial on Dr. McCormick’s study.

The Pharmaceutical Care Management Association, the lobby group representing PBMs, declined an interview request, but challenged the analysis’ portrayal of the role of PBMs in an email. It pointed to a Government Accountability Organization report from July 2019 that found that Part D rebates helped offset spending by about 20% and that PBM compensation was primarily derived from administrative fees and not from maintaining a portion of rebates that the PBM negotiated on behalf of the plan.

Dr. Worthing said in an interview that these bDMARD price hikes are causing access issues, particularly in Medicare where beneficiaries cannot take advantage of manufacturer programs, such as discount cards and copay coupons, and potentially face coinsurance payments based on the list price and not the net-of-rebate price.

From a policy standpoint, he advocated for a cap on out-of-pocket spending for Medicare Part D drugs, which is a feature of legislation (H.R. 3, Lower Drug Costs Now Act of 2019) that is moving through the House of Representatives, most recently passing the House Ways and Means Committee in a party-line vote of 24-17, with 1 Democrat not voting.

Dr. Worthing’s editorial covers a few other policy options, including more financial transparency in the role PBMs play in the drug supply chain, the elimination of rebates in favor of a flat fee for PBMs or requiring all rebates on drugs to be passed through to Part D beneficiaries, penalties on manufacturers for price increases that exceed inflation, and usage of a price index based on what foreign countries pay for the same drug.

Many of the suggestions from Dr. Worthing’s editorial are in H.R. 3 and face an uphill battle to get through the Senate.

Dr. Worthing said that tackling the rebate issue by removing incentives for manufacturers to raise prices in order to offer higher rebates and changing step-therapy rules are things Congress could probably get accomplished as it heads into an election year, but there is a chance it could be even more comprehensive.

“With such an important issue like high drug prices, it probably benefits both parties, and everybody facing an election will be able to go back to their constituents and say, ‘Look we got something done. I was part of this,’ and there is a better chance they will do it if they hear about it from their constituents,” he said.

Dr. Ballreich was less optimistic that H.R. 3 is going to be able to survive.

“The interesting thing with this bill is that a number of pieces of it have been endorsed by President Trump, and the question is, [is] that a meaningful endorsement? Is the Trump administration going to want to use the this plan as a win for him, as a win for showing potential voters that he can work in a bipartisan way, [that] he could take on ‘big drug companies’ – all those successful soundbites? Can then Trump use his power to push this bill through the Senate? I think that is a question mark,” he said, noting that it could take a lot of political capital to counter the powerful industry lobby. Ultimately, he expects that, if drug pricing does make it to the White House, it will go through some changes from where H.R. 3 is right now.

“I don’t think it will pass in its current iteration,” he said.

Each author of Dr. McCormick’s report had funding from different sources, though the funders had no role in the design and conduct of the study. No other disclosures were made.

gtwachtman@mdedge.com

SOURCES: McCormick N et al. Arthritis Rheumatol. 2019 Oct 14. doi: 10.1002/ART.41138; Worthing A. Arthritis Rheumatol. 2019 Oct 14. doi: 10.1002/art.41135.

Rheumatology drugs, like most drugs, are seeing significant price hikes in recent years and, according to a new analysis, those hikes account for the majority of growth in spending.

From 2012 to 2016, annual spending on public-payer claims for 10 biologic disease-modifying antirheumatic drugs (bDMARDs) more than doubled (from $3.8 billion to $8.6 billion), with median drug price increases of 51% in the Medicare Part D prescription drug plans (mean, 54%) and 8% within Medicare Part B drugs administered within the physician office (mean, 21%).

“The prominent bDMARD drug cost increases observed in this study, which were substantially greater under Part D than Part B, even when accounting for rebates, represent a growing burden to taxpayers and beneficiaries,” first author Natalie McCormick, PhD, a research fellow at Massachusetts General Hospital, Boston, and colleagues wrote in Arthritis & Rheumatology.

“The magnitude of these increases is independent from any assessment of value,” the authors continued.

Dr. McCormick and colleagues highlighted the limited effect that rebates negotiated by pharmacy benefit managers (PBMs) for Part D have on patient out-of-pocket costs.

Negotiations “may not necessarily result in lower price increases since pharmacy benefit managers, who negotiate on behalf of Part D plans, retain a percentage of the negotiated rebates as compensation, and higher list prices can achieve higher rebates,” they stated. “While these rebates accrue to insurance plans and pharmacy benefit managers, they do not directly impact Part D beneficiaries’ out-of-pocket costs, which are driven by prerebate prices. Thus, many patients end up paying higher out-of-pocket costs when the list price increases, creating financial barriers to use and adherence.”

They further noted that, for most Part D drugs individually, “drug prices accounted for approximately 50% or more of the increase in spending. Adalimumab and etanercept, two of the oldest bDMARDs, were prescribed to the largest number of Part D beneficiaries (more than 47,000 in 2016) and had the biggest 5-year price increases: 84% and 88%, respectively (72% and 75% respectively, accounting for rebates).”

It is not surprising that the analysis found that prices are rising and are a driving force in spending.

“We know that high launch prices of a new drug is an important consideration for patient access,” Jeromie Ballreich, PhD, a health economist at Johns Hopkins University, Baltimore, said in an interview. “But we also know that a number of these drugs, particularly Humira and Enbrel, have been on the market for a while. They have experienced a tremendous price increase over the past 10 years plus. That’s exactly what the authors found. So that is really not surprising. Analysis of drug spending changes over the time [shows that] it is indeed price increases that really have been driving increases in drug spending.”

Angus Worthing, MD, a rheumatologist at Arthritis & Rheumatism Associates in Washington, D.C., and current chair of the American College of Rheumatology’s Government Affairs Committee, said that the faster price hikes in Part D stood out in the analysis and the role PBMs played in it.

“I was a little surprised at just how much more PBMs were responsible for higher inflation, compared to the part B system,” he said in an interview. “In the McCormick article, drug prices went up 45% after rebates in the Part D space, but only 21% in the Part B space, and we had seen hints that drug prices were going up faster, we just didn’t know just how much faster, so more than double the increase is more than I expected, and it is very concerning to look at that and realize that PBMs are more than doubling an already high inflation rate in drug prices.”

He suggested that part of the rise in Part D bDMARD prices observed in the study might be because of the application of step therapy in Part D.

“In Medicare specifically, step therapy is allowed in Part D but not in Part B – except in Medicare Advantage plans starting in 2019 – and this important difference between Part B and Part D explains how Part D rebates, linked with step therapy, may be the main reason that bDMARD prices rose more in Part D compared to the open formulary system in Medicare Part B,” Dr. Worthing wrote in an editorial on Dr. McCormick’s study.

The Pharmaceutical Care Management Association, the lobby group representing PBMs, declined an interview request, but challenged the analysis’ portrayal of the role of PBMs in an email. It pointed to a Government Accountability Organization report from July 2019 that found that Part D rebates helped offset spending by about 20% and that PBM compensation was primarily derived from administrative fees and not from maintaining a portion of rebates that the PBM negotiated on behalf of the plan.

Dr. Worthing said in an interview that these bDMARD price hikes are causing access issues, particularly in Medicare where beneficiaries cannot take advantage of manufacturer programs, such as discount cards and copay coupons, and potentially face coinsurance payments based on the list price and not the net-of-rebate price.

From a policy standpoint, he advocated for a cap on out-of-pocket spending for Medicare Part D drugs, which is a feature of legislation (H.R. 3, Lower Drug Costs Now Act of 2019) that is moving through the House of Representatives, most recently passing the House Ways and Means Committee in a party-line vote of 24-17, with 1 Democrat not voting.

Dr. Worthing’s editorial covers a few other policy options, including more financial transparency in the role PBMs play in the drug supply chain, the elimination of rebates in favor of a flat fee for PBMs or requiring all rebates on drugs to be passed through to Part D beneficiaries, penalties on manufacturers for price increases that exceed inflation, and usage of a price index based on what foreign countries pay for the same drug.

Many of the suggestions from Dr. Worthing’s editorial are in H.R. 3 and face an uphill battle to get through the Senate.

Dr. Worthing said that tackling the rebate issue by removing incentives for manufacturers to raise prices in order to offer higher rebates and changing step-therapy rules are things Congress could probably get accomplished as it heads into an election year, but there is a chance it could be even more comprehensive.

“With such an important issue like high drug prices, it probably benefits both parties, and everybody facing an election will be able to go back to their constituents and say, ‘Look we got something done. I was part of this,’ and there is a better chance they will do it if they hear about it from their constituents,” he said.

Dr. Ballreich was less optimistic that H.R. 3 is going to be able to survive.

“The interesting thing with this bill is that a number of pieces of it have been endorsed by President Trump, and the question is, [is] that a meaningful endorsement? Is the Trump administration going to want to use the this plan as a win for him, as a win for showing potential voters that he can work in a bipartisan way, [that] he could take on ‘big drug companies’ – all those successful soundbites? Can then Trump use his power to push this bill through the Senate? I think that is a question mark,” he said, noting that it could take a lot of political capital to counter the powerful industry lobby. Ultimately, he expects that, if drug pricing does make it to the White House, it will go through some changes from where H.R. 3 is right now.

“I don’t think it will pass in its current iteration,” he said.

Each author of Dr. McCormick’s report had funding from different sources, though the funders had no role in the design and conduct of the study. No other disclosures were made.

gtwachtman@mdedge.com

SOURCES: McCormick N et al. Arthritis Rheumatol. 2019 Oct 14. doi: 10.1002/ART.41138; Worthing A. Arthritis Rheumatol. 2019 Oct 14. doi: 10.1002/art.41135.

WASHINGTON – The practice of medicine needs a major reset to address the stresses that lead to clinician burnout, a condition now estimated to affect a third to a half of clinicians in the United States, according to a report from an influential federal panel.

The National Academy of Medicine (NAM) on Oct. 23 released a report, “Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being.” The report calls for a broad and unified approach to tackling the root causes of burnout.

There must be a concerted effort by leaders of many fields of health care to create less stressful workplaces for clinicians, Pascale Carayon, PhD, cochair of the NAM committee that produced the report, said during the NAM press event.

“This is not an easy process,” said Dr. Carayon, a researcher into patient safety issues at the University of Wisconsin–Madison. “There is no single solution.”

The NAM report assigns specific tasks to many different participants in health care through a six-goal approach, as described below.

–Create positive workplaces. Leaders of health care systems should consider how their business and management decisions will affect clinicians’ jobs, taking into account the potential to add to their levels of burnout. Executives need to continuously monitor and evaluate the extent of burnout in their organizations, and report on this at least annually.

–Address burnout in training and in clinicians’ early years. Medical, nursing, and pharmacy schools should consider steps such as monitoring workload, implementing pass-fail grading, improving access to scholarships and affordable loans, and creating new loan repayment systems.

–Reduce administrative burden. Federal and state bodies and organizations such as the National Quality Forum should reconsider how their regulations and recommendations contribute to burnout. Organizations should seek to eliminate tasks that do not improve the care of patients.

–Improve usability and relevance of health information technology (IT). Medical organizations should develop and buy systems that are as user-friendly and easy to operate as possible. They also should look to use IT to reduce documentation demands and automate nonessential tasks.

–Reduce stigma and improve burnout recovery services. State officials and legislative bodies should make it easier for clinicians to use employee assistance programs, peer support programs, and mental health providers without the information being admissible in malpractice litigation. The report notes the recommendations from the Federation of State Medical Boards, American Medical Association, and the American Psychiatric Association on limiting inquiries in licensing applications about a clinician’s mental health. Questions should focus on current impairment rather than reach well into a clinician’s past.

–Create a national research agenda on clinician well-being. By the end of 2020, federal agencies – including the Agency for Healthcare Research and Quality, the National Institute for Occupational Safety and Health, the Health Resources and Services Administration, and the U.S. Department of Veterans Affairs – should develop a coordinated research agenda on clinician burnout, the report said.

In casting a wide net and assigning specific tasks, the NAM report seeks to establish efforts to address clinician burnout as a broad and shared responsibility. It would be too easy for different medical organizations to depict addressing burnout as being outside of their responsibilities, Christine K. Cassel, MD, the cochair of the NAM committee that produced the report, said during the press event.

WASHINGTON – The practice of medicine needs a major reset to address the stresses that lead to clinician burnout, a condition now estimated to affect a third to a half of clinicians in the United States, according to a report from an influential federal panel.

The National Academy of Medicine (NAM) on Oct. 23 released a report, “Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being.” The report calls for a broad and unified approach to tackling the root causes of burnout.

There must be a concerted effort by leaders of many fields of health care to create less stressful workplaces for clinicians, Pascale Carayon, PhD, cochair of the NAM committee that produced the report, said during the NAM press event.

“This is not an easy process,” said Dr. Carayon, a researcher into patient safety issues at the University of Wisconsin–Madison. “There is no single solution.”

The NAM report assigns specific tasks to many different participants in health care through a six-goal approach, as described below.

–Create positive workplaces. Leaders of health care systems should consider how their business and management decisions will affect clinicians’ jobs, taking into account the potential to add to their levels of burnout. Executives need to continuously monitor and evaluate the extent of burnout in their organizations, and report on this at least annually.

–Address burnout in training and in clinicians’ early years. Medical, nursing, and pharmacy schools should consider steps such as monitoring workload, implementing pass-fail grading, improving access to scholarships and affordable loans, and creating new loan repayment systems.

–Reduce administrative burden. Federal and state bodies and organizations such as the National Quality Forum should reconsider how their regulations and recommendations contribute to burnout. Organizations should seek to eliminate tasks that do not improve the care of patients.

–Improve usability and relevance of health information technology (IT). Medical organizations should develop and buy systems that are as user-friendly and easy to operate as possible. They also should look to use IT to reduce documentation demands and automate nonessential tasks.

–Reduce stigma and improve burnout recovery services. State officials and legislative bodies should make it easier for clinicians to use employee assistance programs, peer support programs, and mental health providers without the information being admissible in malpractice litigation. The report notes the recommendations from the Federation of State Medical Boards, American Medical Association, and the American Psychiatric Association on limiting inquiries in licensing applications about a clinician’s mental health. Questions should focus on current impairment rather than reach well into a clinician’s past.

–Create a national research agenda on clinician well-being. By the end of 2020, federal agencies – including the Agency for Healthcare Research and Quality, the National Institute for Occupational Safety and Health, the Health Resources and Services Administration, and the U.S. Department of Veterans Affairs – should develop a coordinated research agenda on clinician burnout, the report said.

In casting a wide net and assigning specific tasks, the NAM report seeks to establish efforts to address clinician burnout as a broad and shared responsibility. It would be too easy for different medical organizations to depict addressing burnout as being outside of their responsibilities, Christine K. Cassel, MD, the cochair of the NAM committee that produced the report, said during the press event.

WASHINGTON – The practice of medicine needs a major reset to address the stresses that lead to clinician burnout, a condition now estimated to affect a third to a half of clinicians in the United States, according to a report from an influential federal panel.

The National Academy of Medicine (NAM) on Oct. 23 released a report, “Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being.” The report calls for a broad and unified approach to tackling the root causes of burnout.

There must be a concerted effort by leaders of many fields of health care to create less stressful workplaces for clinicians, Pascale Carayon, PhD, cochair of the NAM committee that produced the report, said during the NAM press event.

“This is not an easy process,” said Dr. Carayon, a researcher into patient safety issues at the University of Wisconsin–Madison. “There is no single solution.”

The NAM report assigns specific tasks to many different participants in health care through a six-goal approach, as described below.

–Create positive workplaces. Leaders of health care systems should consider how their business and management decisions will affect clinicians’ jobs, taking into account the potential to add to their levels of burnout. Executives need to continuously monitor and evaluate the extent of burnout in their organizations, and report on this at least annually.

–Address burnout in training and in clinicians’ early years. Medical, nursing, and pharmacy schools should consider steps such as monitoring workload, implementing pass-fail grading, improving access to scholarships and affordable loans, and creating new loan repayment systems.

–Reduce administrative burden. Federal and state bodies and organizations such as the National Quality Forum should reconsider how their regulations and recommendations contribute to burnout. Organizations should seek to eliminate tasks that do not improve the care of patients.

–Improve usability and relevance of health information technology (IT). Medical organizations should develop and buy systems that are as user-friendly and easy to operate as possible. They also should look to use IT to reduce documentation demands and automate nonessential tasks.

–Reduce stigma and improve burnout recovery services. State officials and legislative bodies should make it easier for clinicians to use employee assistance programs, peer support programs, and mental health providers without the information being admissible in malpractice litigation. The report notes the recommendations from the Federation of State Medical Boards, American Medical Association, and the American Psychiatric Association on limiting inquiries in licensing applications about a clinician’s mental health. Questions should focus on current impairment rather than reach well into a clinician’s past.

–Create a national research agenda on clinician well-being. By the end of 2020, federal agencies – including the Agency for Healthcare Research and Quality, the National Institute for Occupational Safety and Health, the Health Resources and Services Administration, and the U.S. Department of Veterans Affairs – should develop a coordinated research agenda on clinician burnout, the report said.

In casting a wide net and assigning specific tasks, the NAM report seeks to establish efforts to address clinician burnout as a broad and shared responsibility. It would be too easy for different medical organizations to depict addressing burnout as being outside of their responsibilities, Christine K. Cassel, MD, the cochair of the NAM committee that produced the report, said during the press event.

The Centers for Medicare & Medicaid Services needs to be doing a better job overseeing the administrative costs associated with the implementation of work requirements in Medicaid, the Government Accountability Office said in a new report.

thinkstockphotos.com

The government watchdog found two key weaknesses in CMS’s oversight of the administrative costs of the Medicaid demonstration projects related to work requirements for Medicaid.

First, the GAO report notes that no consideration of the administrative costs of the work requirements is given during the administration of the approval process.

The GAO reports that, of five states’ approvals, the estimated administrative costs range from the low end of $6.1 million for New Hampshire (with 50,000 beneficiaries subject to the work requirement) to $271.6 million for Kentucky (with 620,000 beneficiaries subject to the work requirement). Indiana, with 420,000 beneficiaries subject to work requirements, has an estimated cost of $35.1 million.

A significant portion of Kentucky’s funding was for a the development of a new information technology system to help track work requirements.

“GAO found that CMS does not require states to provide projections of administrative costs when requesting demonstration approvals,” the report states. “Thus, the cost of administering demonstrations, including those with work requirements, is not transparent to the public or included in CMS’s assessment of whether a demonstration is budget neutral – that is, that federal spending will be no higher under the demonstration than it would have been without it.”

The GAO also reported that, by not requiring cost estimates, it also fails to meet the demonstration objective of transparency, something that goes hand in hand with budget neutrality.

The second weakness identified by GAO is that current procedures “may be insufficient to ensure that costs are allowable and matched at the correct rate.” Three of the five states examined in the report had received CMS approval for federal funds for administrative costs that were either not allowable for matching or were matched at higher rates than appropriate, based on CMS guidance.

The government watchdog noted that CMS did implement “procedures that may provide additional information on demonstrations’ administrative costs. ... However, it is unclear whether these efforts will result in data that improves CMS’s oversight.”

The GAO made three recommendations in the report. First, the CMS should require states to submit public projections of administrative costs when seeking approval for demonstration projects. Second, the administrative costs should be a part of the calculation for assessing the budget neutrality of demonstration project applications. Finally, CMS should do a better job assessing the risk that federal funds are being used to cover administrative costs that are not allowable and should improve oversight procedures as needed.

The GAO report included the Department of Health & Human Services’s response to the recommendations. To the first, the agency said that “its experience suggests that demonstration administrative costs will be a relatively small portion of total costs and therefore HHS believes making information about these costs available would provide stakeholders little to no value.”

Similarly, to the second recommendation, HHS countered that the information would provide little to no value given that administrative costs represent a relatively small portion of the total demonstration costs.

To the final recommendation on the need for better risk assessment, HHS said its existing approach “is appropriate for the low level of risk that administrative expenditures represent. ... CMS officials told us that they had not assessed wither current procedures sufficiently address risks posed by administrative costs for work requirements and had no plans to do so.”

gtwachtman@mdedge.com

The Centers for Medicare & Medicaid Services needs to be doing a better job overseeing the administrative costs associated with the implementation of work requirements in Medicaid, the Government Accountability Office said in a new report.

thinkstockphotos.com

The government watchdog found two key weaknesses in CMS’s oversight of the administrative costs of the Medicaid demonstration projects related to work requirements for Medicaid.

First, the GAO report notes that no consideration of the administrative costs of the work requirements is given during the administration of the approval process.

The GAO reports that, of five states’ approvals, the estimated administrative costs range from the low end of $6.1 million for New Hampshire (with 50,000 beneficiaries subject to the work requirement) to $271.6 million for Kentucky (with 620,000 beneficiaries subject to the work requirement). Indiana, with 420,000 beneficiaries subject to work requirements, has an estimated cost of $35.1 million.

A significant portion of Kentucky’s funding was for a the development of a new information technology system to help track work requirements.

“GAO found that CMS does not require states to provide projections of administrative costs when requesting demonstration approvals,” the report states. “Thus, the cost of administering demonstrations, including those with work requirements, is not transparent to the public or included in CMS’s assessment of whether a demonstration is budget neutral – that is, that federal spending will be no higher under the demonstration than it would have been without it.”

The GAO also reported that, by not requiring cost estimates, it also fails to meet the demonstration objective of transparency, something that goes hand in hand with budget neutrality.

The second weakness identified by GAO is that current procedures “may be insufficient to ensure that costs are allowable and matched at the correct rate.” Three of the five states examined in the report had received CMS approval for federal funds for administrative costs that were either not allowable for matching or were matched at higher rates than appropriate, based on CMS guidance.

The government watchdog noted that CMS did implement “procedures that may provide additional information on demonstrations’ administrative costs. ... However, it is unclear whether these efforts will result in data that improves CMS’s oversight.”

The GAO made three recommendations in the report. First, the CMS should require states to submit public projections of administrative costs when seeking approval for demonstration projects. Second, the administrative costs should be a part of the calculation for assessing the budget neutrality of demonstration project applications. Finally, CMS should do a better job assessing the risk that federal funds are being used to cover administrative costs that are not allowable and should improve oversight procedures as needed.

The GAO report included the Department of Health & Human Services’s response to the recommendations. To the first, the agency said that “its experience suggests that demonstration administrative costs will be a relatively small portion of total costs and therefore HHS believes making information about these costs available would provide stakeholders little to no value.”

Similarly, to the second recommendation, HHS countered that the information would provide little to no value given that administrative costs represent a relatively small portion of the total demonstration costs.

To the final recommendation on the need for better risk assessment, HHS said its existing approach “is appropriate for the low level of risk that administrative expenditures represent. ... CMS officials told us that they had not assessed wither current procedures sufficiently address risks posed by administrative costs for work requirements and had no plans to do so.”

gtwachtman@mdedge.com

The Centers for Medicare & Medicaid Services needs to be doing a better job overseeing the administrative costs associated with the implementation of work requirements in Medicaid, the Government Accountability Office said in a new report.

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The government watchdog found two key weaknesses in CMS’s oversight of the administrative costs of the Medicaid demonstration projects related to work requirements for Medicaid.

First, the GAO report notes that no consideration of the administrative costs of the work requirements is given during the administration of the approval process.

The GAO reports that, of five states’ approvals, the estimated administrative costs range from the low end of $6.1 million for New Hampshire (with 50,000 beneficiaries subject to the work requirement) to $271.6 million for Kentucky (with 620,000 beneficiaries subject to the work requirement). Indiana, with 420,000 beneficiaries subject to work requirements, has an estimated cost of $35.1 million.

A significant portion of Kentucky’s funding was for a the development of a new information technology system to help track work requirements.

“GAO found that CMS does not require states to provide projections of administrative costs when requesting demonstration approvals,” the report states. “Thus, the cost of administering demonstrations, including those with work requirements, is not transparent to the public or included in CMS’s assessment of whether a demonstration is budget neutral – that is, that federal spending will be no higher under the demonstration than it would have been without it.”

The GAO also reported that, by not requiring cost estimates, it also fails to meet the demonstration objective of transparency, something that goes hand in hand with budget neutrality.

The second weakness identified by GAO is that current procedures “may be insufficient to ensure that costs are allowable and matched at the correct rate.” Three of the five states examined in the report had received CMS approval for federal funds for administrative costs that were either not allowable for matching or were matched at higher rates than appropriate, based on CMS guidance.

The government watchdog noted that CMS did implement “procedures that may provide additional information on demonstrations’ administrative costs. ... However, it is unclear whether these efforts will result in data that improves CMS’s oversight.”

The GAO made three recommendations in the report. First, the CMS should require states to submit public projections of administrative costs when seeking approval for demonstration projects. Second, the administrative costs should be a part of the calculation for assessing the budget neutrality of demonstration project applications. Finally, CMS should do a better job assessing the risk that federal funds are being used to cover administrative costs that are not allowable and should improve oversight procedures as needed.

The GAO report included the Department of Health & Human Services’s response to the recommendations. To the first, the agency said that “its experience suggests that demonstration administrative costs will be a relatively small portion of total costs and therefore HHS believes making information about these costs available would provide stakeholders little to no value.”

Similarly, to the second recommendation, HHS countered that the information would provide little to no value given that administrative costs represent a relatively small portion of the total demonstration costs.

To the final recommendation on the need for better risk assessment, HHS said its existing approach “is appropriate for the low level of risk that administrative expenditures represent. ... CMS officials told us that they had not assessed wither current procedures sufficiently address risks posed by administrative costs for work requirements and had no plans to do so.”

gtwachtman@mdedge.com